Laserfiche WebLink
For aII municipal business IIce nse questions, contact: City of South Bend • Department of Community Investment <br />227 West Jefferson Blvd • Suite 1400S -South Bend, Indiana 46601 •574.235.5912 • F: 574.235.9021 <br />LICENSE APPLICATION FOR -- MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />IV. PERSONAL DATA (Continued) <br />N. Photographs: <br />Company <br />)ort <br />ntil <br />us employment forth ree (3) years prior to I:he date of this application: <br />Address City, State, ZIP Dates <br />(Attach additional sheets if necessary) <br />V. INCLUDE WITH APPLICATION: <br />Three (3) passport photos taken within 6 months of application. <br />VI. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION <br />VIL AFFIRMATION <br />I, hereby, certify and affirm that all of the information I have given in this application is true and <br />accurate to the best of my knowledge. I further certify that I have in no way attempted to <br />mislead the City in this application by omitting facts known to me. I agree to cooperate with any <br />review conducted pursuant to the licensing procedures, including permission to enter and <br />inspect the place of business and facilities in conjunction with such review. I have read and <br />understand the regulations of the Massage Establishment and/or Therapist license found in the <br />City of South Rend Municipal Code, Section 4-35. <br />4 <br />Signature <br />4 <br />Date <br />